CBABE exam review

Review anatomical alterations of the lungs associated with:

Chronic Bronchitis

i. Chronic inflammation and thickening of the wall of the peripheral airways

ii. Excessive mucous production and accumulation

iii. Partial or total mucous plugging of the airways

iv. Smooth muscle constriction of bronchial airways (bronchospasm) – a variable finding

v. Air trapping and hyperinflation of alveoli – may occur in late stages

Review anatomical alterations of the lungs associated with: Emphysema

i. Permanent enlargement and destruction of the air spaces distal to the terminal bronchioles

ii. Destruction of alveolar-capillary membrane

iii. Weakening of the distal airways, primarily the respiratory bronchioles

iv. Air trapping and hyperinflation

Review anatomical alterations of the lungs associated with:

Asthma

i. Smooth muscle constriction of bronchial airways (bronchospasm)

ii. Excessive production of thick, whitish bronchial secretions

iii. Mucous plugging

iv. Hyperinflation of alveoli (air trapping)

v. In severe cases, atelectasis caused by mucous plugging

vi. Bronchial wall inflammation leading to fibrosis (in severe cases, caused by remodeling)

Review anatomical alterations of the lungs associated with:

Cystic fibrosis

i. Excessive production and accumulation of thick, tenacious mucus in the tracheobronchial tree

ii. Partial bronchial obstruction (mucus plugging)

iii. Hyperinflation of alveoli

iv. Total bronchial obstruction (mucus plugging)

v. Atelectasis

Review anatomical alterations of the lungs associated with:

Bronchiectasis

i. Chronic dilation and distortion of bronchial airways

1. From obstructive COPD

ii. Excessive production of often foul-smelling sputum

iii. Bronchospasm

iv. Hyperinflation of alveoli (air trapping)

1. Leads to atelectasis

v. Atelectasis

vi. Consolidation and parenchymal fibrosis

vii. Hemoptysis secondary to bronchial arterial erosion

1. Fibrotic changes

Review clinical manifestations of the following:

Chronic Bronchitis

i. Excessive bronchial secretions

ii. Bronchospasm

iii. Distal airway and alveolar weakening

Review clinical manifestations of the following:

Emphysema

i. Excessive bronchial secretions

ii. Bronchospasm

iii. Distal airway and alveolar weakening

Review clinical manifestations of the following:

Asthma

i. Bronchospasm

ii. Excessive bronchial secretions

Review clinical manifestations of the following:

Bronchiectasis

i. Excessive bronchial secretions

ii. Bronchospasm

iii. Consolidation

iv. Increased alveolar-capillary membrane thickness

Review clinical manifestations of the following:

Cystic Fibrosis

i. Cardiopulmonary clinical

1. Atelectasis

2. Bronchospasm

3. Excessive bronchial secretions

ii. Nonrespiratory clinical

1. Distal intestinal obstruction syndrome (DIOS)

2. Malnutrition and poor body development:

a. Deficiencies of vitamins A,D,E, and K

b. Nasal polyps and sinusitis: 20%

c. Infertility (males): 99%

Review what you would expect to see in PFT’s for:
Chronic bronchitis and Emphysema

1. FVC, FEVt, FEV1/FVC, FEF 25%-75%, FEF 50%, FEF 200-1200, PEFR, MVV

a. Decreased

2. VT, RV, TLC, RV/TLC

a. Normal or increased

3. RV, ERV, IC

a. Normal or decreased

4. VC

a. Decreased

5. FRC

a. Increased

Review what you would expect to see in ABG for:
Chronic bronchitis and Emphysema

Mild to moderate stages

pH increased,
PaCO2 decreased,
HCO3 decreased,
PaO2 decreased,
SaO2/SpO2 decreased

2. severe stages

pH normal,
PaCO2 increased,
HCO3 increased,
PaO2 decreased,
SaO2/SpO2 decreased

Review what you would expect to see in X-rays for:
Chronic bronchitis

a. Lungs may be clear if only large bronchi are affected

b. Occasionally:

i. Translucent

ii. Depressed or flattened diaphragms

c. Common:

i. Cor pulmonale

Review what you would expect to see in X-rays for:

Emphysema

a. Common

i. Translucent

ii. Depressed or flattened diaphragms

iii. Long and narrow heart

iv. Increased retrosternal air space

b. Occasionally

i. Cor pulmonale

ii. Emphysematous bullae

Review what you would expect to see in Lab work for:
Emphysema

1. Hematocrit and hemoglobin

a. Normal – mild to moderate stage

b. Elevated – late stage

2. Electrolytes (abnormal)

a. Late stage:

i. Hypochloremia (Cl-)

1. When chronic ventilatory failure is present

ii. Hypernatremia (Na+)

3. Sputum examination (culture)

a. Normal

Review what you would expect to see in Lab work for:

Chronic bronchitis

1. Sputum examination (culture)

a. Streptococcus pneumoniae

b. Haemophilus influenzae

c. Moraxella catarrhalis

2. Electrolytes (abnormal)

a. Early and late stages:

i. Hypochloremia (Cl-)
          1. When chronic ventilatory failure is present

          ii. Hypernatremia (Na+)

3. Hematocrit and hemoglobin

a. Polycythemia common during the early and late stage

Review what you would expect to see in PFT’s for:

Asthma

1. FVC, FEVt, FEV1/FVC, FEF25%-75%, FEF50%, FEF200-1200, PEFR, MVV

a. Decreased

2. VT, TLC, RV/TLC

a. Normal or increased

3. IRV, ERV, IC,

a. Normal or decreased

4. RV, FRC

a. Increased

5. VC

a. Decreased

What would ABG look like for Asthma

1. Mild to moderate stages (acute respiratory alkalosis)

pH increased,
PaCO2 decreased,
HCO3 decreased,
O2 decreased,
SaO2/SpO2 decreased

2. severe stage (acute respiratory acidosis)

pH decreased,
PaCO2 increased,
HCO3 increased,
O2 decreased,
SaO2/SpO2 decreased

What would lab/sputum examination look like for Asthma:

1. Eosinophilia

2. Charcot-Leyden crystals

3. Casts of mucus from small airways (Kirschman spirals)

4. IgE level (elevated in extrinsic asthma)

What would an x-ray look like for Asthma:

1. Increased anteroposterior diameter (barrel chest)

2. Translucent (dark) lung fields

3. Depressed or flattened diaphragms

PFT for Cystic fibrosis would look like?

1. FVC, FEVt, FEV1/FVC, FEF25%-75%, FEF50%, FEF200-1200, PEFR, MVV

a. Decreased

2. VT, TLC, RV/TLC

a. Normal or increased

3. IRV, ERV, IC

a. Normal or decreased

4. RV, FRC

a. Increased

5. VC

a. Decreased

ABG results for CF would look like?

pH increased,
PaCO2 decreased,
HCO3 decreased,
PaO2 decreased,
SaO2/SpO2 decreased

hypoxia

2. severe stage

pH normal,
PaCO2 increased,
HCO3 increased,
PaO2 decreased,
SaO2/SpO2 decreased

bicarb will be higher

abnormal Lab tests for CF would look like?

1. Hematology

a. Increased hematocrit and hemoglobin

i. Polycythemia

b. Increased WBC

2. Electrolytes

a. Hypochloremia (chronic ventilatory failure)

b. Increased serum bicarbonate (chronic ventilatory failure)

i. Severe stages

3. Sputum examination

a. Gram-positive bacteria

b. Staphylococcus aureus (Most common)

c. Haemophilus influenzae (Most common)

d. Gram-negative bacteria

e. Pseudomonas aeruginosa (Most common)

f. Stenotrophomonas maltophilia

g. Burkholderia cepacia complex

What would you expect to see on x-ray for CF?

1. Translucent (dark) lung fields

2. Depressed or flattened diaphragms

3. Right ventricular enlargement

a. Cor pulmonale

4. Areas of atelectasis and fibrosis

5. Tram-tracks

6. Bronchiectasis (often a secondary complication)

7. Pneumothorax (spontaneous)

8. Abscess formation (occasionally)

PFT for Bronchiectasis when it is obstructive in nature (moderate to severe)

1. FVC, FEVt, FEV1/FVC, FEF25%-75%, FEF50%, FEF200-1200, PEFR, MVV

a. Decreased

2. VT, TLC, RV/TLC

a. Normal or increased

3. IRV, ERV, IC

a. Normal or decreased

4. RV, FRC

a. Increased

5. VC

a. Decreased

What would PFT look like for Bronchiectasis when restrictive in nature - moderate to severe

1. FVC

a. Decreased

2. FEVt, FEF25%-75%, FEF50%, FEF200-1200, PEFR, MVV

a. Normal or decreased

3. FEV1/FVC

a. Normal or increased

i. >70% (80%)

4. VT

a. Normal or decreased

5. IRV, ERV, RV, VC, IC, FRC, TLC

a. Decreased

6. RV/TLC

a. Normal

What would ABG look like for Bronchiectasis?

1. Mild to moderate stages (acute alveolar hyperventilation with hypoxemia) (acute respiratory alkalosis)

pH increased,
PaCO2 decreased,
HCO3 decreased,
PaO2 decreased,
SaO2/SpO2 decreased

2. severe stage (chronic ventilatory failure with hypoxemia) (compensated respiratory acidosis)

pH normal,
PaCO2 increased,
HCO3 increased,
PaO2 decreased,
SaO2/SpO2 decreased

What would abnormal lab results look like for Bronchiectasis?

1. increased hematocrit and hemoglobin

a. in response to low levels of O2 in blood

b. increase risk of blood clots

c. more pressure on/in heart to push or more blood

2. elevated WBC if acutely elevated

3. sputum examination

a. streptococcus pneumoniae

b. haemophilus influenzae

c. pseudomonas aeruginosa

d. anaerobic organisms

What would an x-ray look like in Bronchiectasis?

1. Primarily obstructive in nature

a. Translucent (dark) lung fields

b. Depressed or flattened diaphragms

c. Long and narrow heart (pulled down by diaphragms) (diaphragm is flat)

d. Enlarged heart (when heart failure is present)

e. Areas of consolidation and/or atelectasis may or may not be seen (restrictive pressure going on)

f. Tram-tracks
2. Areas of consolidation and/or atelectasis

3. Infiltrates (suggesting pneumonia)

4. Increased opacity

a. With restriction, rings on CXR in lower lobes

What type of emphysema is seen with Alpha1- antitrypsin deficiency?

Panacinar (or panlobular) emphysema

We use FeNO testing with asthma, what level of FeNO would indicate using controller medication?

a. 50ppb in adults / 35ppb in children

b. Step 2

Define Charcot-Leyton crystals.

a. Breakdown products of eosinophils, type of WBC

b. When eosinophils degranulate (release their contents) they produce a protein called galectin-10

c. Associated with eosinophilic inflammation (increased number of eosinophils)

d. Small, colorless crystals under a microscope (appear as hexagonal or diamond-shaped structures)

What are recurrent symptoms seen with asthma?

Cough, wheeze, difficulty breathing, chest tightness

What are common pathogens seen in patients with cystic fibrosis when a sputum culture is done?

Gram-positive bacteria

Staphylococcus aureus most common

Haemophilus influenzae most common

Gram-negative bacteria

Pseudomonas aeruginosa most common (use TOBI)

Stenotrophomonas maltophilia

Burkholderia cepacia complex

Medications are commonly used for CF and what the action of the medication is.

Bronchodilators specific to CF patients:

• Inhaled bronchodilators are routinely administered to all patients with CF, especially during the following situations:

• Immediately before the patient receives airway clearance therapy or exercise to help mobilize airway secretions.

• Immediately before the patient receives inhalation of nebulized hypertonic saline, antibiotics and/or DNase (dornase alpha) to offset bronchial constriction that can occur with use of these agents and to help improve the penetration and distribution of the drugs throughout the airways.

Recommended bronchodilators include beta2-adrenergic agonists such as the short-acting agent albuterol or long-acting agents such as salmeterol or formoterol. The anticholinergic agent ipratropium bromide and the longer acting tiotropium are also used to treat patients with CF.

Medications are commonly used for CF and what the action of the medication is:
Mucolytics specific to CF patients:

• Inhaled DNase (dornase alpha) (Pulmozyme)
- has been shown to be especially helpful in the management of patients with moderate to severe CF.

- This aerosolized agent is an enzyme that breaks down the DNA of the thick bronchial mucus associated with chronic bacterial infections with CF.

- Dornase alpha has shown good results in improving the lung function of patients with CF while reducing the frequency and severity of respiratory infections

Medications are commonly used for CF and what the action of the medication is:
Inhaled hypertonic saline

may be administered to help hydrate thick mucus in the airways of patients with CF who are 6 years of age or older,
have a chronic cough,
and have a reduced FEV1.

- A typical treatment regimen is,
first, the administration of a bronchodilator (e.g., albuterol),
followed by 4 mL of a 3% to 7% saline solution, twice a day.

Medications are commonly used for CF and what the action of the medication is:
Inhaled mannitol

- is a second-line option for adult CF patients who fail the combination of DNase and hypertonic saline for airway clearance.

- Because inhaled mannitol may cause bronchospasm,
the initial dose must be administered with a bedside spirometer

- and oxygen saturation monitor in the presence of an experienced respiratory therapist.

Medications are commonly used for CF and what the action of the medication is: N-acetylcysteine

- is not recommended for use as an airway mucolytic in patients with CF.

- It has the potential to cause airway inflammation,
bronchospasm,
and decreased ciliary function,
along with its disagreeable odor
and relatively high cost.

How is CF managed?

The primary goals are to:
- prevent pulmonary infections,
- reduce the amount of thick bronchial secretions,
- improve air flow,
- and provide adequate nutrition

The patient and the patient’s family should be instructed regarding the disease and the way it affects bodily functions

What are 3 different types of anatomic alterations seen on an x-ray of bronchiectasis patients?

1. Varicose bronchiectasis (Fusiform)
   

2. Cylindrical bronchiectasis (Tubular)
   

3. Cystic Bronchiectasis (Saccular)

What is Varicose bronchiectasis (Fusiform)?

Bronchi are dilated and constricted in an irregular fashion

similar to varicose veins

Distorted, bulbous shape

What is Cylindrical bronchiectasis (Tubular)?

Bronchi are dilated and rigid and have regular outlines similar to a tube

What is Cystic Bronchiectasis (Saccular)?

Bronchi progressively increase in diameter until they end in large, cystlike sacs in the lung parenchyma

What is a hallmark sign of bronchiectasis?

Chronic cough with production of large quantities of foul-smelling sputum is a hallmark of bronchiectasis

Based on symptoms and clinical scenario be able to determine appropriate FiO2 for COPD patients.
Oxygen Therapy Protocol

The Oxygen Therapy Protocol is used to treat the hypoxemia associated with COPD—and, importantly, to help decrease the patient’s work of breathing and myocardial work.

According to GOLD, the initial supplemental oxygen for the COPD patient should be______

administered with a target SaO2 of 88% to 92%.

Venturi masks (high-flow devices) offer more precise control of FIO2 than nasal cannulas!!

Long-term oxygen therapy is indicated in the patient with stable disease who has a:

• PaO2 at or below 55 mm Hg or an SaO2 less than 88%, with or without hypercapnia confirmed two or more times over a 3-week period; or a

• PaO2 between 55 and 60 mm Hg or an SaO2 of 88% if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit greater than 55%).

• Once placed on long-term oxygen therapy, the patient should be reevaluated between 60 and 90 days later with repeat ABG or oxygen saturation determinations, while the patient is breathing the prescribed level of oxygen to determine if oxygen is still therapeutic and indicated. See Oxygen Therapy Protocol algorithm

(Protocol 10.1)

What level of alpha1-antitrypsin is considered abnormal?

Alpha1-antitrypsin deficiency (AATD) screening:

When a younger patient (<45 years old) presents with a history and clinical indicators associated with COPD, an AATD screen should be considered.

A serum level below 15% to 20% of normal value is highly suggestive of emphysema caused by AATD.

What is the most accurate indicator of an asthmatic patient not responding to therapy and impending respiratory failure?

Altered mental status (confusion or drowsiness), a silent chest with absent breath sounds, and signs of exhaustion such as reduced or absent respiratory effort

Describe mucus of the bronchiectasis patient.

Large quantities of thick tenacious layered foul smelling sputum

What type of medication is given for an increased white blood cell count?

Antibiotics like:

Pathogen: Streptococcus pneumoniae,

Haemophilus influenzae, Moraxella catarrhalis-
Amoxicillin-clavulanate or cefuroxime axetil or respiratory quinolone (levofloxacin or moxifloxacin or gemifloxacin) or

macrolide/ ketolide or TMP-SMX

Pathogen: Pseudomonas aeruginosa, Acinetobacter
Ceftazidime or cefepime or aztreonam or a carbapenem and vancomycin

Describe biphasic response in regards to asthma.

The patient with extrinsic asthma may demonstrate an early asthmatic (allergic) response,

a late asthmatic response, or a biphasic asthmatic response.

The early asthmatic response begins within minutes of exposure to an inhaled antigen and resolves in about 1 h.

A late asthmatic response begins several hours after exposure to an inhaled antigen but lasts much longer.

The late asthmatic response may or may not follow an early asthmatic response.

An early asthmatic response followed by a late asthmatic response is called a biphasic response.

What is the mMRC?

a. Modified medical research council

i. Dyspnea scale

ii. To measure the level of functional disability caused by breathlessness a key symptom of chronic respiratory diseases

iii. Providers use scale to determine the severity of breathlessness and its impact on activities like walking or even dressing, which can help in managing in COPD and other conditions

What ABG values would you expect to see in a patient during a severe asthma attack?

pH decreased,

PaCO2 increased,

HCO3 increased,

PaO2 decreased,

SaO2/SpO2 decreased